Unstable Spine Injuries Research Articles

Functional outcomes in unstable complete subaxial cervical spinal injuries with respiratory paralysis and/or hemodynamic instability

IntroductionSubaxial cervical spine injuries (SCSI) can lead to disastrous consequences such as quadriplegia, with/without respiratory paralysis (RP) and hemodynamic instability (HDI). Till date, there is no literature available for reporting outcomes of SCSI patients specifically pertaining to those presenting with RP/HDI and ours is the first study to document the same. MethodsRetrospective 6-year study from a tertiary trauma centre database including patients >/= 18 years of operated SCSI. Only patients with ASIA A grade with admission RP/HDI and unstable injuries (fractures, subluxations) were included. Patients with ASIA grade B and above, patients with non-osseous injuries (such as disc herniation, central cord syndrome etc.) were excluded. Results24 cases were analysed. C5 and C6 levels were the commonest. Vertebral listhesis/subluxation was the predominant radiological finding. The mean age was 47.4 years (22–79 years) and all, except one were males. Fall from height and road traffic accident (RTA) were the most common mechanisms of injury. The most common surgery was anterior discectomy and fusion followed by corpectomy. The overall mortality rate was 22/24 (92)%. Cord edema and hemorrhage had significant association with survival. None of the grade A survivors with HDI/RP showed improvement. The mean FU duration was 18.5 months (range, 16.5–20.5 months). ConclusionsSubaxial ASIA A cervical spine injuries with pre-operative RP/HDI is an indicator for non-improvement. This is the first study documenting outcome in such patients. The mortality rate in these patients is very high and is an extremely poor prognostic factor for recovery. Hence, surgery in such patients need to be decided judiciously, especially in developing countries that has a significant financial impact on the family members.

Imaging Outcomes of MRI After CT in Pediatric Spinal Trauma: A Single-center Experience.

Imaging has an essential role in the diagnostic workup of suspected pediatric spinal trauma. The most suitable imaging method is still being debated and needs to be considered regarding the patient, injury, and local resources. Magnetic resonance imaging (MRI) is often performed after computed tomography (CT) in case of neurological symptoms or suspected ligamentous disruption. However, it is unclear if the MRI yields significant additional value after CT if the spinal cord injury is not suspected and if the MRI could be used as the sole imaging modality in an emergency department. This study aimed to assess the diagnostic value of emergency MRI after CT in suspected spinal trauma in children and adolescents. The imaging data and medical records of patients 17 years of age and younger with emergency spinal CT and MRI over 8 years were retrospectively reviewed. The primary study outcome was the diagnostic accuracy of the 2 imaging modalities in detecting surgically treated spinal injuries. The study population consisted of 100 patients. Computed tomography and magnetic resonance imaging demonstrated all 7 surgically treated injuries, although one of the injuries was initially missed with CT. Magnetic resonance imaging revealed more injuries, but none of the injuries visible on CT required surgical fixation. Magnetic resonance imaging was able to exclude unstable injuries in patients who had highly suspicious or unequivocal findings on CT. Magnetic resonance imaging and computed tomography were both highly accurate in detecting unstable pediatric spinal injuries requiring surgical treatment. Magnetic resonance imaging seems not to reveal additional unstable injuries after adequately interpreted spinal CT. Level III-retrospective observational study.

A Ten-Year Retrospective Cohort Study on Neck Collar Immobilization in Trauma Patients with Head and Neck Injuries.

Background and Objectives: In the context of prehospital care, spinal immobilization is commonly employed to maintain cervical stability in head and neck injury patients. However, its use in cases of unclear consciousness or major trauma patients is often precautionary, pending the exclusion of unstable spinal injuries through appropriate diagnostic imaging. The impact of prehospital C-spinal immobilization in these specific patient populations remains uncertain. Materials and Methods: We conducted a retrospective cohort study at Taipei Tzu Chi Hospital from January 2009 to May 2019, focusing on trauma patients suspected of head and neck injuries. The primary outcome assessed was in-hospital mortality. We employed multivariable logistic regression to investigate the relationship between prehospital C-spine immobilization and outcomes, while adjusting for various factors such as age, gender, type of traumatic brain injury, Injury Severity Score (ISS), Revised Trauma Score (RTS), and activation of trauma team. Results: Our analysis encompassed 2733 patients. Among these, patients in the unclear consciousness group (GCS ≤ 8) who underwent C-spine immobilization exhibited a higher mortality rate than those without immobilization. However, there was no statistically significant difference in mortality among patients with alert consciousness (GCS > 8). Multivariable logistic regression analysis revealed that advanced age (age ≥ 65), unclear consciousness (GCS ≤ 8), major traumatic injuries (ISS ≥ 16 and RTS ≤ 7), and the use of neck collars for immobilization (adjusted OR: 1.850, 95% CI: 1.240-2.760, p = 0.003) were significantly associated with an increased risk of mortality. Subgroup analysis indicated that C-spine immobilization was significantly linked to an elevated risk of mortality in older adults (age ≥ 65), patients with unclear consciousness (GCS ≤ 8), those with major traumatic injuries (ISS ≥ 16 and RTS ≤ 7), and individuals in shock (shock index > 1). Conclusions: While our findings do not advocate for the complete abandonment of neck collars in all suspected head and neck injury patients, our study suggests that prehospital cervical and spinal immobilization should be applied more selectively in certain head and neck injury populations. This approach is particularly relevant for older individuals (age ≥ 65), those with unclear consciousness (GCS ≤ 8), individuals experiencing major traumatic injuries (ISS ≥ 16 or RTS ≤ 7), and patients in a state of shock (shock index ≥ 1). Our study employs a retrospective cohort design, which may introduce selection bias. Therefore, in the future, there is a need for confirmation of our results through a two-arm randomized controlled trial (RCT) arises, as this design is considered ideal for addressing this issue.

Cervical Collar-Associated Pressure Injury in Pediatric Trauma Patients: A Western Pediatric Surgery Research Consortium Study

BackgroundHealthcare-associated pressure injuries (HAPI) are known to be associated with medical devices and are preventable. Cervical spine immobilization is commonly utilized in injured children prior to clinical clearance or for treatment of an unstable cervical spinal injury. The frequency of HAPI has been quantified in adults with cervical spine immobilization but has not been well-described in children. The aim of this study was to describe characteristics of children who developed HAPI associated with cervical immobilization. MethodsWe analyzed a retrospective cohort of children (0–18 years) who developed a stage two or greater cervical HAPI. This cohort was drawn from an overall sample of 49,218 registry patients treated over a five-year period (2017–2021) at ten pediatric trauma centers. Patient demographics, injury characteristics, and cervical immobilization were tabulated to describe the population. ResultsThe cohort included 32 children with stage two or greater cervical HAPI. The median age was 5 years (IQR 2–13) and 78% (n = 25) were admitted to the intensive care unit. The median (IQR) time to diagnosis of HAPI was 11 (7–21) days post-injury. The majority of cervical HAPI (78%, 25/32) occurred in children requiring immobilization for cervical injuries, with only four children developing HAPI after wearing a prophylactic cervical collar in the absence of a cervical spine injury. ConclusionAdvanced-stage HAPI associated with cervical collar use in pediatric trauma patients is rare and usually occurs in patients with cervical spine injuries requiring immobilization for treatment. More expedient cervical spine clearance with MRI is unlikely to substantially reduce cervical HAPI in injured children. Level of EvidenceLevel III (Epidemiologic and Prognostic).

The sequence of the treatment of combined fractures of the pelvis, spine, and extremities in polytraumatized patients.

'Damage control' is the therapeutic strategy in the treatment of polytraumatized patients and aims at securing vital functions and controlling bleeding with a favorable effect on the post-traumatic immune response. The post-traumatic immune dysfunction is based on a disturbed balance between immunostimulatory and anti-inflammatory mechanisms. The extent of the immunological 'second hit' can be limited by delaying deferable surgical therapies until organ stabilization has been achieved by the treating surgeon. Pelvic sling is easy to apply and noninvasive with effective pelvic reduction. Pelvic angiography vs pelvic packing are not antagonistic, but rather should be considered as complementary methods. Operating as early as possible on unstable spinal injuries with confirmed or suspected neurological deficits by decompression and stabilization with a dorsal internal fixator. Dislocations, unstable or open fracture, vascular involvement, and compartment syndrome are considered emergency indications. In extremity fracture treatment, primary definitive osteosynthesis is often dispensed with and instead, temporary stabilization with an external fixator is performed.

Case Report-Traumatic L5-S1 Instability: Are Upright Radiographs Potentially Dangerous?

Traumatic lumbosacral instability is a rare but potentially devastating injury. These injuries are frequently associated with neurologic injury and often result in long-term disability. Despite their severity, radiographic findings can be subtle, and multiple reports exist in which these injuries were not recognized on initial imaging. Transverse process fractures, high-energy mechanisms, and other injury features have been suggested as indications for advanced imaging, which has a high degree of sensitivity in detecting unstable injuries. A 21-year-old man presented to our level I trauma center after being ejected in a rollover motor vehicle collision. He sustained multiple injuries, including multiple lumbar transverse process fractures and a unilateral superior articular facet fracture of S1. Initial supine computed tomography (CT) images showed no displacement of the fracture and no listhesis or instability. Subsequent upright imaging in a brace, however, demonstrated significant displacement of the fracture with dislocation of the contralateral L5-S1 facet joint and significant anterolisthesis. The patient underwent open posterior reduction and stabilization of L4-S1 followed by L5-S1 anterior lumbar interbody fusion. The patient demonstrated excellent alignment on postoperative imaging. At 3 months postoperatively, he had returned to work, was ambulating without assistance, and reported minimal back discomfort and no lower extremity pain, numbness, or weakness. This case serves as a warning that supine CT imaging alone may not be sufficient to rule out unstable lumbar spine injuries, such as traumatic L5-S1 instability, and that upright radiographs in these potentially unstable injuries may represent a hazard to patients. Fractures involving the pedicle, pars, or facet joints as well as multiple transverse process fractures and/or a high-energy mechanism of injury should all raise suspicion of instability and warrant additional imaging. This article provides guidance on approaching treatment for patients with potential traumatic lumbosacral instability.

Cervical single open-door laminoplasty with or without local lateral mass screw fixation and fusion to treat cervical spinal cord injuries accompanied by segmental spinal canal stenosis.

Retrospective. To investigate the efficacy of cervical single open-door laminoplasty with and without local lateral mass screw fixation and fusion as treatments for cervical spinal cord injuries accompanied by multisegmental spinal canal stenosis. The Second Affiliated Hospital, School of Medicine, Zhejiang University. Of all enrolled patients, 42 formed a stable group who underwent cervical single open-door laminoplasty alone and 14 formed an unstable group who underwent the procedure combined with lateral mass screw fixation and fusion. Neurological function was evaluated before surgery, at discharge, and at final follow-up using the American Spinal Cord Injury Association (ASIA) impairment scale and the Japanese Orthopedic Association (JOA) score. ASIA scores reflected improved neurological function in 52.5% of the stable group (15 with grade-D and 4 with grade-A injuries did not improve) and 45.5% of the unstable group (3 with grade-D and 3 with grade-A injuries did not improve). Postoperative JOA scores reflected 19.1% ± 21.6% improvement in the stable group and 18.6% ± 18.4% improvement in the unstable group (P > 0.05). Final follow-up JOA scores reflected 49.2% ± 31.7% improvement in the stable group and 47.1% ± 39.2% improvement in the unstable group (P > 0.05). Laminoplasty combined with local fusion aided the treatment of unstable cervical spinal cord injuries and spinal stenosis. Such stenosis is the main pathological factor causing multiple spinal cord compressions in patients with cervical spinal cord injuries.

Rib fixation for flail chest physiology and the facilitation of safe prone spinal surgery: illustrative case.

Spine fractures are frequently associated with additional injuries in the trauma setting, with chest wall trauma being particularly common. Limited literature exists on the management of flail chest physiology with concurrent unstable spinal injury. The authors present a case in which flail chest physiology precluded safe prone surgery and after rib fixation the patient tolerated spinal fixation without further issue. Flail chest physiology can cause cardiovascular decompensation in the prone position. Stabilization of the chest wall addresses this instability allowing for safe prone spinal surgery. Chest wall fixation should be considered in select cases of flail chest physiology prior to stabilization of the spinal column in the prone position. Further research is necessary to identify patients that are at highest risk to not tolerate prone surgery.

Risk Factors for Postoperative Complications After Surgical Treatment of Type B and C Injuries of the Thoracolumbar Spine

Unstable thoracolumbar spinal injuries benefit from surgical fixation. However, perioperative complications significantly affect outcomes in surgicallytreated spine patients. We evaluated associations between risk factors and postoperative complications in patients surgically treated for thoracolumbar spine fractures. We conducted a retrospective multicenter study collating data from 21 spine centers across 9 countries on the treatment of AOSpine types B and C injuries of the thoracolumbar spine treated via a posterior approach. Comparative analysis was performed between patients with postoperative complications and those without. Univariate and multivariable analyses were performed. Among 535 patients, at least 1 complication occurred in 43%. The most common surgical complication was surgical-site infection (6.9%), while the most common medical complication was urinary tract infection (13.8%). Among 136 patients with American Spinal Injury Association (ASIA) Impairment Scalelevel A disability, 77.9% experienced at least 1 complication. The rate of complications also rose sharply among patients waiting >3 days for surgery (P<0.001), peaking at 68.4% among patients waiting ≥30 days. On multivariable analysis, significant predictors of complications were surgery at a governmental hospital (odds ratio= 3.38, 95% confidence interval= 1.73-6.60), having ≥1 comorbid illness (2.44, 1.61-3.70), surgery delayed due to health instability (2.56, 1.50-4.37), and ASIA Impairment Scalelevel A (3.36, 1.78-6.35), while absence of impairment (0.39, 0.22-0.71), ASIAlevel E (0.39, 0.22-0.67) and, unexpectedly, delay caused by operating room unavailability (0.60, 0.36-0.99) were protective. Types B and C thoracolumbar spine injuries are associated with a high risk of postoperative complications, especially common at governmental hospitals, and among patients with comorbidity, health instability, longer delays to surgery, and worse preoperative neurologic status.

"Floating Cervical Spine Injuries": Craniocervical Dissociation with Associated, Noncontiguous, Unstable Cervical or Cervicothoracic Spine Fracture.

Advances in prehospital life support of patients who have sustained high-energy trauma have resulted in an increase in the number of patients with craniocervical dissociations (CCDs) surviving. With better imaging and more severely injured patients surviving, we are now seeing other associated injuries. CCDs in association with unstable, noncontiguous, subaxial spine injuries have not been described. The objective of this study was to (1) describe this injury pattern and its characteristics, including the mechanism of injury, injury levels, and neurological deficits, and (2) understand prognosis and outcome. After institutional review board approval, a retrospective study of patients who sustained CCD in association with an unstable, circumferential, subaxial, or cervicothroacic spine injury (C3-T2) between January 1, 2003, and August 31, 2018, was done. Review of imaging was performed to identify spine injury localization and type. Demographic data, mechanism of injury, neurological status, type of treatment, and patient outcomes were obtained from the electronic medical records. One hundred seventeen patients with CCD were identified, of which 105 had full spine radiographs. Thirteen (8 male and 5 female) had an associated, noncontiguous, unstable cervical, or cervicothoracic injury. Mean age was 45.4 ± 19 years. No exam could be obtained in 6; in the other 7, 1 was American Spinal Injury Association (ASIA) E, 1 ASIA D, and 5 ASIA A. Operative management of both injuries was planned for all 13 patients; however, 2 died before surgery. At discharge, there were 9 survivors with mean follow up of 2 years; 4 patients were independent (3 ASIA D, 1 ASIA E), and 5 were dependent (1 ASIA C, 4 ASIA A). Approximately 12% of patients with CCD have a floating cervical spine injury. Floating cervical spine injuries have an unfavorable prognosis with 69% surviving to hospital discharge but only 31% functioning independently (ASIA D or E). 4. Floating cervical spine injuries need to be recognized to optimize prognosis, yet even in the best of circumstances, prognosis is guarded.

Open versus minimally invasive fixation of thoracic and lumbar spine fractures in patients with ankylosing spinal diseases

PurposePosterior multilevel fixation of traumatic instability in ankylosing spinal disease (ASD) can be performed by open surgery (OS) or minimally invasive surgery (MIS). We investigated whether both methods differ based on the reduction results and perioperative parameters.MethodsIn this retrospective cohort study, OS and MIS groups were investigated. The bisegmental Cobb angles and dislocation angles were measured using pre- and postoperative CT images, and the initial malalignment and achieved reduction were calculated. Cut-seam time, calculated blood loss, transfusion number, fluoroscopy time, pedicle screw placement accuracy, duration of ICU stay, in-patient stay, and complications (bleeding, postoperative thrombosis and embolism, and postoperative mortality) were recorded.ResultsSeventy-five ASD patients with spine fractures (Ø 75 ± 11 years, male: 52, female: 23) (MIS: 48; OS: 27) were included in this study. The extent of reduction did not differ in the OS and MIS groups (p = 0.465; MIS:− 1 ± 3°, OS:−2 ± 6°). The residual postoperative malalignment angle was not significantly different (p = 0.283). Seventy-eight of the implanted screws (11%) showed malpositioning. No difference was found between OS and MIS (MIS, 37 [7%]; OS, 41 [16%]; p = 0.095). MIS was associated with less blood loss (OS: 1.28 ± 0.78 l, MIS: 0.71 ± 0.57 l, p = 0.001), cut-seam time (MIS: 98 ± 44 min, OS: 166 ± 69 min, p < 0.001), and hospital stay (MIS: Ø14 ± 16 d, OS: Ø38 ± 49 d, p = 0.02) than OS.ConclusionOS and MIS show equally limited performance in terms of the fracture reduction achieved. The MIS technique was superior to OS based on the perioperative outcome. Therefore, MIS should be preferred over OS for unstable spinal injuries, excluding C-type fractures, in ASD patients without neurological impairment.

Airway management in the adult patient with an unstable cervical spine.

The ideal airway management of patients with unstable spinal injury presents a perennial challenge for anaesthesiologists. With competing interests, potentially catastrophic complications, and a scarcity of evidence to support common practices, it is an area rich with dogma and devoid of data. This review seeks to highlight recent evidence that improves our assurance that what we do to manage the airway in the unstable cervical spine is supported by data. The increasing range of available technology for intubation provides important opportunities to investigate the superiority (or otherwise) of various techniques - and a chance to challenge accepted practice. Long-held assumptions regarding spinal immobilisation in the context of airway management may require refinement as a true base of evidence develops. Video laryngoscopy may replace direct laryngoscopy as the default technique for endotracheal intubation in patients with suspected or confirmed spinal instability. Immobilisation of the unstable cervical spine, manually or with rigid cervical collars, is increasingly controversial. It may be that hard collars are used in specific circumstances, rather than as universal precaution in the future.There are no recent data of significantly high quality to warrant wholesale changes to recommended airway management practice and in the absence of new information, limiting movement (in the suspected or confirmed unstable cervical spine) remains the mainstay of clinical practice advice.

A prospective study on role of magnetic resonance imaging in management of acute spinal trauma and assessing the extent of neurological deficit

Background: For Imaging neurological parts, like the spinal cord, magnetic resonance imaging (MRI) has been the gold standard. The use of magnetic resonance imaging (MRI) in the acute management of patients with spinal cord injuries has risen dramatically. Objectives: This study was conducted to evaluate the diagnostic role of magnetic resonance imaging in management of acute spinal trauma and to assess the extent of neurological deficit. Material and Methods: Thirty patients of spinal trauma. The patients undergoing MR imaging, magnetic resonance images were analysed and skeletal injuries, signal changes in vertebrae, ligaments, soft tissues were noted. Associated spinal cord injury findings were also noted, which helped in assessing the initial neurological deficit and compared with (ASIA) impairment scale. Results: Out of 30 patients of spinal trauma. 53.3 % injuries were in cervical region and 46.6% in thoracolumbar region. Most of the traumatic spinal injuries in cervical spine were unstable. (68.75%) and thoracolumbar spine were stable injuries (42.85%). Unstable spinal injuries (56.66%) in cervical and thoracolumbar were operated and stabilised. Cord oedema (36.6%) and next cord compression (33.3%) were common presentations of cord injuries; cord transection and compression have worse neurological deficit and presented with ASIA score A/B at the time of admission. Conclusion: CT provides superior depiction of bony anatomy but important limitation of this technique is inability to provide screening for ligamentous injury and spinal cord lesions. MRI is superior in this regard. Because of its high contrast resolution, absence of bony artifacts, multiplanar ability, and variety of pulse sequences, MRI allows for a more precise diagnosis of spinal trauma.

Rotational stability of thoracolumbar junction fixation systems

Objective To compare the rotational stability of fusion constructs using bisegmental fixation of Th12-L2 vertebrae with anterior stabilization or pedicle screw fixation.Material and Methods The strength, rigidity and limit of elasticity in the “injured vertebral motion segments (VMS) – bisegmental anterior stabilization” system under dislocating rotational loads were estimated. The data obtained were compared with the similar characteristics of the “injured VMS – bisegmental 4-screw transpedicular metal construction” system and intact spine segments.Results Under rotational loads the limits of elasticity of injured spine segments of Th12-L2 with anterior stabilization and transpedicular screw fixation (TSF) is 45.5 and 41.7%, respectively, and the general strength is 66.4% and 80%, respectively, as compared with those intact VMS. Rigidity parameters of anterior-stabilized and pedicle screw fixated VMS with unstable damage of L1 are 60.2 and 93.9%, accordingly, in comparison with those intact VMS.Conclusion No significant differences were observed between bisegmental anterior stabilization and bisegmental pedicle screw fixation of thoracolumbar junction in terms of the key mechanical properties. When treating patients with unstable thoracolumbar spine injuries using bisegmental anterior stabilization or transpedicular fixation with 4-screw spinal system possible rotation motion amplitude of operated segments must not exceed 50% of maximum physiological limits.

Dural tear with multiple nerve root entrapment simultaneously after unstable spine injury: Intraoperative finding

Spinal cord injuries (SCIs) caused by trauma that frequently occur are dural tears and cerebrospinal fluid (CSF) leaks. They are not always detected with neuroimaging. Hence, the authors reported two cases of the dural tear with multiple nerve root entrapment after spine injury and described how managed. This case report was about two patients who had unstable spinal fractures. All patients have an asymmetrical neurological deficit. The following magnetic resonance imaging features have analyzed the presence of CSF leakage, epidural haematoma, and spine fractures. Both cases revealed intraoperative finding dural tear with multiple nerve root entrapment. We performed decompression with spinal fixation with a posterior approach, and then the patients were sent home without complication. During the follow-up period, none of the patients developed complications. The severe neurological deficit, fracture of laminar, and ligamentum flavum disruption on the MRI in patients were predictable factors in our cases.

Outcome of Unstable Thoracolumbar Fracture Following Long Segment Posterior Fixation

Introduction: Fractures of the thoracolumbar region are the most common injuries of the vertebral column and burst fractures are the most frequent. The purpose of this study was to see the radiological and functional outcome after long segment posterior fixation in unstable thoracolumbar spine injury with incomplete neurological deficit.&#x0D; Methods: A total of 146 cases were included in this prospective case series from January 2014 to December 2018 through non randomized purposive sampling. All the patients were operated with long segment posterior fixation and postero-lateral fusion by Autogenous cancellous bone graft. Postoperative functional outcome was assessed both clinically by ODI, VAS, ASIA and radiologically by Bridwell criteria. Postoperative follow up was conducted at 2nd, 6th,12th and finally 6 monthly.&#x0D; Results: The mean Cobb angle at pre-operative was 21.5 ±8.9 and at final follow-up was 11±4.57 in this study (p-value&lt;0.05). At final follow up 1 grade improvement occurred in 116(79.5%) patients and 2 grade improvement in 36 (20.5%). Regarding ODI and VAS, moderate disability (25%) with mild pain (16%) was found at final follow up with a Bridwell fusion grade II (48%).&#x0D; Conclusion: Long segment transpedicular screw fixation in unstable thoracolumbar spine injury with incomplete neurological deficit is an effective method of treatment. This method enhances neurological and functional recovery with an acceptable fusion rate&#x0D; J Bangladesh Coll Phys Surg 2021; 39(2): 114-122

Anterior-posterior view by full-body digital X-ray to rule out severe spinal injuries in Polytraumatized patients

BackgroundSpinal injuries are present in 16–31% of polytraumatized patients. Rapid identification of spinal injuries requiring immobilization or operative treatment is essential. The Lodox-Statscan (LS) has evolved into a promising time-saving diagnostic tool to diagnose life-threatening injuries with an anterior-posterior (AP)-full-body digital X-ray.MethodsWe aimed to analyze the diagnostic accuracy and the interrater reliability of AP-LS to detect spinal injuries in polytraumatized patients. Therefore, within 3 years, AP-LS of polytraumatized patients (ISS ≥ 16) were retrospectively analyzed by three independent observers. The sensitivity and specificity of correct diagnosis with AP-LS compared to CT scan were calculated. The diagnostic accuracy was evaluated by using the area under the ROC (receiver operating characteristic curve) for sensitivity and specificity. Interrater reliability between the three observers was calculated using Fleiss’ Kappa. The sensitivity of AP-LS was further analyzed by the severity of spinal injuries.ResultsThe study group included 320 patients (48.5 years ±19.5, 89 women). On CT scan, 207 patients presented with a spinal injury (65%, total of 332 injuries). AP-LS had a low sensitivity of 9% (31 of 332, range 0–24%) and high specificity of 99% (range 98–100%). The sensitivity was highest for thoracic spinal injuries (14%). The interrater reliability was slight (κ = 0.02; 95% CI: 0.00, 0.03). Potentially unstable spinal injuries were more likely to be detected than stable injuries (sensitivity 18 and 6%, respectively).ConclusionThis study demonstrated high specificity with low sensitivity of AP-LS in detecting spinal injuries compared to CT scan. In polytraumatized patients, AP-LS, implemented in the Advanced Trauma Life Support-algorithm, is a helpful tool to diagnose life-threatening injuries. However, if spinal injuries are suspected, performing a full-body CT scan is necessary for correct diagnosis.

Spine surgery in pregnant women: a multicenter case series and proposition of treatment algorithm

PurposeSpinal diseases requiring urgent surgical treatment are rare during pregnancy. Evidence is sparse and data are only available in the form of case reports. Our aim is to provide a comprehensive guide for spinal surgery on pregnant patients and highlight diagnostic and therapeutic aspects.MethodsThe study included a cohort of consecutive pregnant patients who underwent spinal surgery at five high-volume neurosurgical centers between 2010 and 2017. Perioperative and perinatal clinical data were derived from medical records.ResultsTwenty-four pregnant patients were included. Three underwent a preoperative cesarean section. Twenty-one patients underwent surgery during pregnancy. Median maternal age was 33 years, and median gestational age was 13 completed weeks. Indications were: lumbar disk prolapse (n = 14; including cauda equina, severe motor deficits or acute pain), unstable spine injuries (n = 4); intramedullary tumor with paraparesis (n = 1), infection (n = 1) and Schwann cell nerve root tumor presenting with high-grade paresis (n = 1). Two patients suffered transient gestational diabetes and 1 patient presented with vaginal bleeding without any signs of fetal complications. No miscarriages, stillbirths, or severe obstetric complications occurred until delivery. All patients improved neurologically after the surgery.ConclusionSpinal surgical procedures during pregnancy seem to be safe. The indication for surgery has to be very strict and surgical procedures during pregnancy should be reserved for emergency cases. For pregnant patients, the surgical strategy should be individually tailored to the mother and the fetus.

Timing of intervention for spinal injury in patients with polytrauma

ObjectiveThe optimal timing of surgical intervention of spinal fractures in patients with polytrauma is still controversial. In the setting of trauma to multiple organ systems, an inappropriately timed definitive spine surgery can lead to increased incidence of pulmonary complications, hemodynamic instability and potentially death, while delayed surgical stabilisation has its attendant problems of prolonged recumbency including deep vein thrombosis, organ-sp ecific infection and pressure sores. MethodsA narrative review focussed at the epidemiology, demographics and principles of surgery for spinal trauma in poly-traumatised patients was performed. Pubmed search (1995–2020) based on the keywords – polytrauma OR multiple trauma AND spine fracture AND timing, present in “All the fields” of the search tab, was performed. Among 48 articles retrieved, 23 articles specific to the management of spinal fracture in polytrauma patients were reviewed. ResultsSpine trauma is noted in up to 30% of polytrauma patients. Unstable spinal fractures with or without spinal cord injury in polytrauma require surgical intervention and are treated based on the following principles - stabilizing the injured spine during resuscitation, acute management of life-and limb-threatening organ injuries, “damage control” internal stabilisation of unstable spinal injuries during the early acute phase and, definitive surgery at an appropriate window of opportunity. Early spine fracture fixation, especially in the setting of chest injury, reduces morbidity of pulmonary complications and duration of hospital stay. ConclusionRecognition and stabilisation of spinal fractures during resuscitation of polytrauma is important. Early posterior spinal fixation of unstable fractures, described as damage control spine surgery, is preferred while a delayed definitive 360° decompression is performed once the systemic milieu is optimal, if mandated for biomechanical and neurological indications.

Factors influencing the pedicle screw fixation stability in patients with unstable lumbar and thoracolumbar spine injuries

Background. One of the reasons for the lack of standardized approaches for treatment of lumbar and thoracolumbar spine traumatic injuries is inconclusive information on relative contribution of various factors to pedicle screw fixation stability.Objective. To determine risk factors that influence pedicle screw fixation stability in patients with unstable traumatic injuries of a lumbar spine and thoracolumbar junction.Material and methods. This was a retrospective evaluation of 192 spinal instrumentations. Patients with type А3, A4, B1, B2 and C injuries of lumbar and thoracolumbar spine were enrolled. Pedicle screw fixation was used either as a stand-alone technique or in combination with anterior column reconstruction. If required, decompression of nerve roots and spinal cord was performed. Cases with pedicle screw fixation failure were registered. Logistic regression analysis was used to assess predictive significance of potential risk factors. Results. Complication rate growth was associated with a decrease in bone radiodensity, posterior decompression extensiveness, lumbosacral fixation and residual kyphotic deformity. Anterior column reconstruction and additional pedicle screw installation led to a decline in complication rate while anterior decompression and fixation length did not influence fixation stability. Conclusion. In most cases, pedicle screw fixation system failure is associated with altered bone quality; however, surgical approach may also impact complication rate and should be taken into account planning surgical intervention. Anterior column reconstruction and additional pedicle screw installation are associated with the decline in complication rate; the influence of those options is comparable. Anterior decompression does not influence pedicle screw fixation stability; consequently, it is preferable in cases with considerable risk of pedicle screw fixation failure.